Mental-health professionals use apocalyptic language in speaking of their financial arrangements with the managed-care companies that dominate their field. The major targets of their ire are low reimbursement rates and annual limits on the number of mental-health visits patients may make. “It's disgusting,” Zimmerman says. “Insurance limits on mental-health treatment are the norm, rather than the exception. If you have difficult-to-control diabetes, you can have as many visits as you need. If you have difficult-to-control depression, you may be limited to 20 visits a year.”
A study of mental-health benefits, published in the September-October 2003 issue of Health Affairs, found that though 98 percent of insured employees had some kind of mental-health coverage, 32 percent were allowed no more than 20 outpatient visits per year, and 22 percent had to pay a higher share of the costs for mental-health care than for other types of health care.
Even Medicare treats mental illness differently from other medical conditions, requiring patients to bear half the cost, rather than the usual 20 percent for other types of outpatient care.
In our study, most people did get better in the number of visits for which their coverage paid, but a significant minority ran into trouble. Of the 80 percent who secured treatment through their health plans, 23 percent said they had some type of problem with it. Problems included restrictions on the number of visits, long waits for appointments, hassles with red tape, or difficulty finding a doctor in the plan directory who was willing to accept new patients.
These frustrations, as well as privacy concerns, may lead some people to avoid using their health insurance to pay for mental-health care. Federal privacy laws make it illegal for mental-health professionals to disclose, without the patient's permission, “personal notes” containing the therapists' impressions. But health plans are allowed access to information about diagnosis, drugs prescribed, treatment plan, and prognosis. So a health plan or employer may be able to find out that a person is getting, say, Zoloft for depression, but not the therapist's opinion on the causes of depression.
That's thin protection for people concerned that having an antidepressant prescription on their record might result in insurance or employer discrimination. Whether from lack of coverage or fears about using it, 19 percent of our respondents said their health plan didn't pay for any of their mental-health treatment. As a result, many spent $500 or more out of pocket for therapy over the previous year. And of the 57 percent of respondents who said they had stopped their mental-health treatment, 14 percent said it was because they couldn't afford to continue.